Levels of Care and Treatment Options

 

 

 

TREATMENT SETTINGS & OPTIONS

• Brief Intervention
• Screening & Assessment
• DetoxificationOutpatient Treatment
• Day/Evening Treatment
• Residential Treatment
• 12 step facilitation
• Minnesota model
• therapeutic community
• Continuing Care
• Sober Living i.e. Oxford houses
• Self-help Groups

TREATMENT STAGES
Developmental Models of Recovery (Recovery is a complex process that emerges in stages over time.  Each developmental stage of recovery has its own unique theme, recovery goal, and recover tasks.)

– CENAPS Model of Recovery

• transition
• stabilization
• early recovery
• middle recovery
• late recovery
• maintenance

– Motivational Model of Recovery

• precontemplation (get off my back!)
• contemplation (I feel stuck)
• planning (I will make changes tomorrow)
• action (here I go!)
• maintenance (relapse prevention)
• termination

– Other Developmental Models

TREATMENT OPTIONS AND SERVICES:

DETOXIFICATION (DETOX)

Detoxification is a medical procedure designed to stabilize individuals who have consumed mood-altering substances to toxic levels. Going “cold-turkey” from alcohol or drugs in people who have consumed on a daily basis can lead to withdrawal. Since withdrawal can result in potentially life-threatening medical complications, around the clock supervision by medical staff is recommended. The length of stay in an alcohol and drug detox program varies but is typically 3-5 days. Longer stays in detox may be required if opioids or alcohol are involved or if there are other medical conditions. During detox, little or no counselling is provided to the client.

Typically, detox is provided as a “stand-alone” service apart from residential drug treatment. However, some centres offer both detox and residential treatment. This allows a client to be admitted promptly without requiring “clean-time” and permits clients to transfer immediately from detox to residential treatment (patients in government programs often have to return home and wait for an available residential bed). Other terms: stabilization, withdrawal management. Technically, detoxification is not considered “treatment” since there is typically little or no counseling provided during detox.

OUTPATIENT ALCOHOL AND DRUG TREATMENT

Outpatient is a counselling service offered once or twice a week. The number of sessions may vary depending on progress of client. Outpatient treatment can be one-on-one or in groups. Employee Assistance Programs (EAPs)  typically provide outpatient counselling as part of their service package; Outpatient treatment can precede inpatient treatment if a client’s addiction severity requires additional supervision and structure. Outpatient treatment can also follow inpatient treatment. Commonly referred to as “continuing care” or “aftercare,” this form of outpatient treatment is a necessary transition for a client when returning to his/her home community.

Day treatment is an alcohol and drug program offered several hours per day, several days (or nights) per week for several weeks. Day treatment is an alternative to residential drug rehab since the client returns home every day after treatment. Typically, day treatment is less expensive than residential treatment because it does not include the cost of accommodation and, frequently, meals. Day treatment, however, needs to be close enough to home so that the client does not have to pay for overnight accommodation. The one risk to day treatment is that there is not as much supervision as there is in residential treatment. Another disadvantage to day treatment is that, since clients do not spend as much time together, the cohesiveness of the peer group may not be as tight as one would find in residential treatment. Finally, theavailability of day treatment is limited in Canada in comparison to outpatient or residential treatment.

Other terms: intensive outpatient treatment.

 RESIDENTIAL (OR INPATIENT) DRUG TREATMENT

Residential alcohol and drug treatment, sometimes referred to as primary treatment, is a program that is necessary when substance use has progressed to dependence. Residential alcohol and drug rehab programs provide around the clock supervision, group and individual therapy, education, meals, and accommodation. Inpatient addiction treatment is similar to residential treatment but is typically reserved for hospital-based settings. An important component of the residential treatment program is discharge planning. This service helps clients connect to rehab programs in their home community such as outpatient alcohol and drug counselling and self-help groups.

Other terms: inpatient, intensive inpatient, rehab, rehabilitation, primary treatment.

Sober living is a less-intensive drug rehab program that is usually a minimum of 60 days in duration that can last as long as two years. Sober living is provided to clients who have completed residential treatment but require a greater level of support than what is available at home. Amount of time allocated to actual therapy, level of supervision, and qualifications of staff varies but is generally less than residential drug treatment. Clients may or may not be permitted to work while in a sober living program.

The sober living options are most appropriate for clients that are in high risk of relapsing. These clients benefit when moving from the rehabilitaion facility straight into a transitional living. If clients do not have sober living in theirome community then professionals should  recommend a temporary relocation to a city where a good sober living program is available.

Other terms: support recovery, extended care, second stage, stage 2 housing, recovery home, half-way house, Oxford houses, transition homes.

SELF-HELP GROUPS

Self-help groups are composed of individuals who desire to quit drugs and/or alcohol as a common goal. These groups are run by peers instead of by health professionals such as counsellors, doctors or psychologists. There is no cost to participants and are supported by voluntary donation of members. Better known self-help groups include Alcoholics Anonymous (AA) or Narcotics Anonymous (NA).

Visit the Canada Drug Rehab website for a directory of NA, AA, CA, and Al-Anon meetings in your home community.

There is a growing body of knowledge making a strong case both academically and experientially that individuals who combine self-help group support with addiction counselling have the greatest opportunity for successful recovery.

Other terms: mutual-support groups, peer support, mutual aid, meetings, 12 Step meetings, AA, Alcoholics Anonymous, NA, Narcotics Anonymous, CA, Cocaine Anonymous.

American Society for Addiction Medicine (ASAM) is the foremost authority on drug treatment stages. In 1991, ASAM published the
Patient Placement Criteria (1) which focus on six assessment dimensions to define bio-psychosocial (2) severity:

1. Acute intoxication and/or withdrawal potential
2. Biomedical conditions and complications
3. Emotional/behavioral conditions and complications
4. Treatment acceptance/resistance
5. Relapse potential
6. Recovery environment

Criteria listed under these six dimensions help guide placement to one of four levels of care (stages), which is the first part of matching patients to treatment.

The four levels of care are named to be descriptive of the intensity of service provided:

• Level I–Outpatient Treatment
• Level II–Intensive Outpatient/Partial Hospitalization
• Level III–Medically Monitored Intensive Inpatient Treatment
• Level IV–Medically Managed Intensive Inpatient Treatment

Provincial health ministries like the Patient Placement Criteria because it helps ensure that tax dollars are not spent unnecessarily on care that exceeds the minimum required for effective treatment.

The main benefit to clients is that they receive treatment in the least intensive – but safe – setting where they can test out recovery skills in as close to ” real world ” situations as possible and minimize re-entry problems.

Levels   of care
Criteria   dimensions	Level   I   Outpatient treatment	Level   II   Intensive outpatient   treatment	Level   III   Medically monitored   intensive inpatient treatment	Level   IV   Medically managed   intensive inpatient treatment
1   Acute intoxication   and/or withdrawal potential	No   withdrawal risk	Minimal   withdrawal risk	Severe   withdrawal risk but manageable in Level III	Severe   withdrawal risk
2   Biomedical conditions   and complications	None or   very stable	None or nondistracting   from addiction treatment and manageable in Level II	Requires   medical monitoring but not intensive treatment	Requires   24-hour medical, nursing care
3   Emotional and   behavioral conditions and complications	None or   very stable	Mild   severity with potential to distract from recovery	Moderate   severity needing a 24-hour structured setting	Severe   problems requiring 24-hour psychiatric care with concomitant addiction   treatment
4   Treatment acceptance   and resistance	Willing to   cooperate but needs motivating and monitoring strategies	Resistance   high enough to require structured program, but not so high as to render   outpatient treatment ineffective	Resistance   high despite negative consequences and needs intensive motivating strategies   in 24-hour structure	Problems in   this dimension do not qualify patient for Level IV treatment
5   Relapse potential	Able to   maintain abstinence and recovery goals with minimal support	Intensification   of addiction symptoms and high likelihood of relapse without close monitoring   and support	Unable to   control use despite active participation in less intensive care and needs   24-hour structure	Problems in   this dimension do not qualify patient for Level IV treatment
6   Recovery environment	Supportive   recovery environment and/or patient has skills to cope	Environment   unsupportive but with structure or support, the patient can cope	Environment   dangerous for recovery necessitating removal from the environment; logistical   impediments to outpatient treatment	Problems in   this dimension do not qualify patient for Level IV treatment
SOURCE:   Center for Substance Abuse Treatment. Intensive Outpatient Treatment for   Alcohol and Other Drug Abuse. Treatment Improvement Protocol (TIP) Series,   No. 8. DHHS Pub. No. (SMA) 94-2077. Rockville, MD: Center for Substance Abuse   Treatment, 1994b.

It is important to note that self-help groups are not listed in the Patient Placement Criteria because most self-help groups are focused on self-care not professional care. That is, support is provided by the peer group, not counsellors or medical professionals. However, self-help groups such as AA and NA hold meetings in many hospitals across North America and are recommended by both outpatient and residential counsellors as an important adjunct to treatment.

(1) Source: Hoffmann, N.G., Halikas, J.A., Mee-Lee, D., and Weedman, R.D. Patient Placement Criteria for the Treatment of Psychoactive Substance Use Disorders. American Society of Addiction Medicine, Washington, D.C., 1991.

(2) Note: Bio-psychosocial is an approach that treats the whole person including psychological, biological and social needs …